- Now, I'm recording.
Alright, so what are some factors
that influence mental health?
That's what we need to talk about.
Mental health can change over time, ask the questions,
asking questions like are you anxious?
What affects your mental health?
Questions like that.
Is their mood and their affect congruent?
So, if they're really sad,
is the affect,
like what their facial expression is showing,
is it the same?
Sometimes, you'll have people who are really anxious
and they're laughing, they're smiling, laughing at you.
Is it the same?
Be knowledgeable about local resources
and that's something you learn over time.
And, if you don't know,
what do you do?
You ask.
You ask if you suspect
that your patient has a mental health issue
that's not diagnosed,
you can always ask your nurse that you're working with,
your clinical instructor.
How might substance use or abuse influence mental health.
For some people mental health is exacerbated
or made worse with drug abuse.
I don't know if you've ever seen this,
but like some people who abuse drugs,
when they are abusing the drugs,
they're just be really angry, or paranoid, or...
Or just anxious.
I had a brother, he passed away due to complications
from an overdose,
but he, whenever he was abusing drugs,
he'd get really violent.
He'd get really paranoid.
So, what's affecting them.
Cultural considerations.
That's a big one.
Social stigma.
I don't wanna go into detail about each of these things,
but just know that that can affect as well.
Factors that may influence mental health,
economic and social factors, not having enough money,
unhealthy lifestyles, drug abuse,
being unhealthy as far as food consumption.
I think the big one is drug abuse.
Exposure to violence or trauma, that can really...
Someone may not have any mental health issues
until they've had an experience with violence or traumas.
So, keep that in mind.
Like what...
What kind of...
What was the originator?
What caused this?
Personality factors,
spiritual or cultural factors may also play into this,
and you're gonna have a full semester just on psych,
and that's gonna kind of go through all of this.
Psychosocial development impairments of neurological system.
Maybe, they had a head injury
and now their personality is completely different.
Genetics is another one.
Depression is often seen in families,
like a grandfather had issues with depression.
You may see it in the children as well,
like the child and then the grandchildren, potentially.
We look at alert and oriented times three or four.
Some of you were asking me about the times four,
what does that mean?
So, we have to ask questions.
And, usually I ask this when I come into the room,
I say, I'm just gonna look at your name band,
can you tell me your name and date of birth?
And, I'm comparing what they say
to what's on their name band.
And, then at the same time, I might say, oh,
could you just tell me where you are, and what year it is,
or what the date is.
And, you might also, the times four is situation.
Why are they in the hospital?
And, I've seen this in the ICU where they knew their name,
they knew to date because we told them,
they knew that they were in a hospital,
but they didn't know why they were in a hospital.
So, just kind of asking them that extra question,
why are you here?
Place, can you tell me where you are?
Date, I mentioned all of this.
Another thing that you might,
and this isn't, they're not quite oriented,
but if they, you can say like,
are you in a gas station, a hospital, or a school?
And, then they might be able to pick the right answer
from asking those questions.
And, then, oh, just one other thing I wanna mention
is reorienting your patient, saying,
asking them those questions,
maybe they get it wrong.
And, then just saying, so and so,
just wanna remind you of the date.
I just wanna remind you of where you are.
And, I've done that with patients over a 12 hour period,
and by the time we get to the end of the 12 hour period,
they were able to answer all these questions correctly.
They just needed to be reoriented.
Level of consciousness, or L O C, capital L O C,
is we look at these five different levels of consciousness.
Alert is they're in the room.
Their eyes are open.
They're looking around.
They may still be confused, but they're alert.
Lethargic is you have to go to them and kind of...
Kind of maybe tap their shoulder and say, hey, so and so,
and they open their eyes.
They're able to answer the questions correctly,
but they fall back asleep
and that could be due to a metabolic issue.
It could be due to sedation.
It could be due to a head injury.
There's a lot of reasons,
but we're just looking, are they alert?
Are they lethargic?
Obtunded,
obtunded is you go in the room
and you're like yelling their name,
and they're able to open their eyes.
They respond slowly with some confusion usually.
And, they're aware of the environment, potentially.
Stuporous, awakens to vigorous shaking.
You have to really wake them up.
You might have to take your knuckle
and go over their sternum and rub like this.
That's why it talks about painful stimuli.
You're causing that painful...
I don't know if you...
You should do it to yourself.
Just take your knuckle and just rub over your sternum.
It's, it can be, it's pretty painful.
Painful stimuli may return to unresponsive sleep.
And, then comatosed, remains unresponsive to all stimuli,
eyes stay closed.
Now, it can be comatosed for a little bit,
maybe 'cause they had a lot of sedation,
but if it's sedation related, it should...
They should improve once the sedation wears off,
but it can also occur due to metabolic disorders.
It can occur due to head injury.
I've seen all of this, so...
So, this is really important.
This slide I'm gonna say is really, really important.
Do you wanna highlight this slide?
I'm not gonna go into dementia versus delirium too much,
but dementia is usually
when we look at like Alzheimer's versus vascular dementia.
Is it like a pathological disorder
versus vascular dementia could be like...
My grandfather had this.
Basically, he had all these micro strokes
and it caused what we call vascular dementia.
It can usually, dementia is usually chronic, irreversible,
which is the key word there.
They have memory loss, challenges with planning,
problem solving,
they can't do ADLs, changes in mood.
Delirium is a little bit different.
It can, they can show the signs of dementia with delirium.
It is reversible with treatment of underlying condition,
review the chart in your text.
So, sometimes we have older patients
that come into the hospital
and we are doing all these things to them.
We're giving them meds.
We're...
They're not in their normal environment.
They are not sleeping.
You think in the hospital, you would sleep,
but that doesn't happen all the time.
So, they're really tired.
They become delirious
and they kind of act like they have dementia,
but once we know, maybe, we take the medication away,
we allow them to sleep.
We treat the underlying condition.
For example, maybe they have a UTI and we treat that.
Then, it goes away, the delirium.
So, and you're gonna learn more
about the treatment of older patients
when you take gerontology in the fall.
So, I'm not gonna talk too much
about what's on the right side of this slide.
I'm gonna focus more on the left side,
but just know that if you're taking care of someone,
there is your general assessment,
and then there's your more focused assessment.
So, general routine screening versus focused assessment,
so your general routine screening
of someone's neurological status,
I don't care if you're in the postpartum unit,
or if you're on the psych unit,
or if you're on a med surg unit,
we have general assessments.
So, level of consciousness, are they alert?
Are they lethargic? Are they stuporous?
Posture? Is their posture erect?
Is it slouched? Is it uneven?
Their gait, that's their ability to walk.
We'll talk more about that, body movements,
do they have extra twitching?
Behavior and affect, are they crying constantly,
despite what's happening around them?
Are they laughing hysterically?
What's going on there?
Screen for tobacco, ETOH, illicit drugs.
People can have really extreme behavior
when they are, or seizures too,
when they are withdrawing from drugs.
So, just keep that in mind,
observe their dress and grooming.
Someone with a mental status issue
or mental status diagnosis might have, be...
Have dress that's poorly kept, dirty, poor grooming,
observe facial expressions,
assess speech, orientation, concentration.
Are they able to concentrate?
Are they oriented?
Is their speech kind of, does it make sense
or is it, does it not make sense?
The opposite would, does it not make sense?
Assess memory, thought process, perception.
I've had patients that were really paranoid.
They were thinking someone's gonna come kill them.
It wasn't true,
but because of their mental health status,
they were really believing that.
They really felt like someone was gonna kill them,
and if you feel like someone's gonna kill you,
you're gonna be anxious, right?
You're gonna be afraid.
That might escalate.
So, clinical pearls,
speech is influenced by experience, level of education,
and culture.
So, when you're assessing someone's speech, is it clear?
Is it, what's their educational background?
What's their cultural background?
Is this their first language, second language,
third language?
Where do they fall in all of that?
Eye contact, facial expressions
may defer in various cultures.
There's some cultures that would consider it,
I know in Africa,
there's a few cultures there
that would consider it extremely rude
for you to maintain eye contact.
So, knowing your patient's cultural background is important,
your client may or may not be a reliable historian.
That's a big one right there.
Your patient may be pleasant,,
but they may not be able to tell you
that they have diabetes or hypertension, or they...
You're maybe relying on their kids
or their caregiver to give you accurate information.
And, then monitoring environment and distractions.
Some patients, if they have a certain caregiver,
with a certain personality,
or maybe there's a lot of lights on your unit,
or there's a lot of noise,
that can cause an escalation in behavior.
So, just kind of observing your patient.
What makes them more anxious? What makes them less anxious?
Trying to figure out,
and sometimes your patient can't even tell you
what's going on.
They're just so anxious or they have...
Their mental health is in such a state
that they can't tell you.
So, being observant, watching the environment,
what is a trigger for them?
So, and it could be tricky.
It's almost like a puzzle trying to figure out
what makes that patient more comfortable, less comfortable.
GCS, so GCS is something you really need to grasp.
It's a...
It's helps us determine injury to the brain.
It helps us determine level of consciousness.
So, the first part of it is eye opening,
the second part is verbal response,
and then motor response.
So, do you, when you walk into the room,
are their eyes already open?
They get a four points for that.
If you come in the room and you ask them something,
or you say their name,
do they open their eyes to you talking to them?
Sometimes, you have to cause some pain,
like I was talking about the sternal rub
to have them open their eyes.
Maybe, they're really sedated.
They have a lot of medication.
And, then the other one is no opening, no eye opening.
Verbal response, are they oriented?
Number two, are they confused when you ask them questions,
inappropriate response, maybe you're saying,
how are you doing?
And, they're like the weather, and the table,
and it doesn't make sense.
The other one, incomprehensible sound or speech,
especially with someone who has had a stroke,
they might be moaning.
They might be groaning when you talk to them.
And, sometimes that clears up, it gets better,
or it can become worse.
They become non-verbal.
So, that would be something you would report
if it goes backwards.
They're also non-verbal if they're intubated,
if they have a breathing tube in.
The next one is motor response, do they obey commands?
If you ask them to squeeze your hands
or push down on the pedal, when you do the dorsa flection,
and plantar flection.
Are they able to do that?
Maybe, they're confused,
but they're able to follow commands.
Purposeful movement to painful stimulus.
That would be like, let's say I pinch their right.
This is my left shoulder.
If I pinch their left shoulder,
are they able to take their hand and like push you away?
Do they, are they purposeful?
And, that's purposeful, they're able to push you away.
The next one is withdrawals from pain.
That would be like,
I would do this on all four extremities,
but I would take a, maybe a pen,
or we usually do a pen.
And, I don't know if you can see what I'm doing,
I'm taking the pen and I'm putting it over my nail bed,
and then I'm pinching,
and you should do that to yourself to see how it feels,
but I'm doing that.
And, what you want them to do is pull away,
they should be able to pull away from that painful stimulus.
And, then we'll talk about decorticate
and decerebrate posturing.
That's typically with a really bad pain head injury,
not a good sign.
We'll talk about that.
And, then no motor response.
So, if you look at the bottom,
it says minor brain injury,
and it's not always an injury.
It could be like sedation.
It would be 13 to 15 points.
Moderate brain injury is nine to 12 points.
And, then severe brain injury is three to eight.
A person who is dead will get three points, right?
So, it's good to know their GCS,
when a patient's coming in into the ED,
or if they're coming from the ED to you,
what's their GCs, what was their GCs upon arrival?
Has it gotten worse? Has it gotten better?
Typically, for me, in the ICU, when I'm working,
we do neuro assessments every hour.
So, every hour, from one hour to the next,
I'm assessing what is their GCS from one hour to the next,
has it changed?
Has it improved?
If it's changed, why has it changed?
Do I need to call the doctor about that?
For the floor nursing, it's every four hours
to every eight hours.
So, if you're doing it every four hours,
you wanna compare to four hours prior,
or the last time you saw that patient,
here's a picture of decerebrate and decorticate posturing.
And, it, I'm not gonna read through this,
but you can read through it.
And, so if they're doing this,
they're kind of posturing like so,
that's more of a upper brain stem damage.
Oops, sorry.
And, then the opposite would be damage
to one or both corticospinal tracts, okay.
So, I have only seen this a few times.
It was on a patient,
patients who've had head injuries
and they were about to go to surgery.
And, then when they came back from surgery,
they were not doing this anymore.
So, you might see this and it's not a good sign, okay?
Neurological system, I'm not gonna go into great detail,
but you should know the different parts of the brain,
the different parts of the spinal column, the brain stem,
all that.
You should know that.
Again, I'm not gonna go into great detail,
but this talks about the understanding the different...
So, if they have a frontal head injury
or a parietal head injury, an occipital head injury,
or temporal head injury,
that's gonna affect different parts
of their neurological muscular function.
So, this is something you would, you wanna know,
might be on the test.
So, if a kid gets hit in the head,
like the occipital area,
that might affect their vision, right?
It might affect their reading and understanding.
If their frontal area is hit,
that might affect their speech and all that.
So, just understanding all of those concepts,
and I could give you story, after story, after story
of different head injuries that I've seen
and the loss of function.
And, sometimes people regain function.
Sometimes, the initial injury, plus the swelling
causes someone to lose function,
and then they regain it once the swelling goes down.
So, it can look really scary at first
when you see a brain injury,
but keep in mind that sometimes it's the initial swelling
that makes it look bad.
And, we try to treat that swelling.
We don't want the swelling to get worse.
If they have a bleed, we don't want that bleed to get worse.
And, hopefully all of that kind of...
The swelling goes down and then they improve.
And, then their function comes back.
Central versus peripheral nervous system.
So, your central is just giving you the distinction
between the two.
I would know this.
I'm not gonna go into the detail about all of this.
Just another breakdown of the nervous system.
The nervous system is so fascinating.
I could talk about this for hours,
one, because I work in surgical ICU
and we have part of our surgical ICU is the neuro ICU.
So, I've seen a lot of injuries to different parts
of the neuro system.
One thing I wanna say is it takes,
a neuro nurse needs to be very detail oriented,
needs to be very...
Just be able to pick up on subtle changes,
because it's those subtle changes
that can be indicative of something worse,
that something worse might be happening.
So, if you're like someone who's really detail oriented,
you really love how the neuro system works,
this might be your specialty.
So, keep that in mind for the future.
Common neurological problems,
I'm not gonna go into detail about each of these.
Headaches is one, we think about headaches,
oh, everybody has headaches,
but not everybody has headaches.
And, headaches can tell us a lot
about how the head is doing.
If someone has a head injury
and they have a headache,
that can tell us,
is the swelling in the head getting worse?
Seizures, not a good sign,
but that can tell us also how they're doing.
Dizziness, numbness, and tingling in the hands feet.
Again, not good.
If it gets worse, you would wanna report that.
If it's a new finding, you wanna report that.
Any changes in the five senses.
I know, with COVID, we talk about loss of taste or smell,
but I had a...
Some patients will have strokes,
not strokes, but like...
I'm not a neurologist,
but they have these kind of seizures
that makes them smell burnt toast.
And, if they smell that burn toast,
we need to call the doctor for them to be treated.
So, it just depends you know.
A loss of taste, loss of smell, all that.
Difficulty swallowing, speaking.
We think about the word dysphasia.
Is that because of a stroke,
a neurological problem?
Falls, big falls, if your patient is prone to fall,
they are at risk for head injuries, okay?
Head injuries is huge, especially in your older population.
So, if this is someone who is prone to falls,
it's some...
This is someone that
you're gonna want to see occupational therapy,
physical therapy.
You wanna keep them safe.
You don't want them hitting their head.
Change in cognition or memory,
picking up on that is important,
to see what's going on, what's causing this.
In a younger person,
if they haven't had a trauma,
and they suddenly lose memory, or cognition,
or have neurological changes,
it could be a lot of things.
But, one of the things I often see
is it could be a tumor.
So, taking that seriously.
Muscle control,
if they start having fasciculations,
it's like sudden quick movements, tremors, ticks,
myoclonus, or chorea,
all of that is in your term sheets,
but sudden muscle, loss of muscle...
Sudden loss of muscle control
needs to be investigated, okay?
I don't care if it's young, old,
it needs to be investigated.
Better figure out what's going on.
Talk about strokes.
So, there's different types of strokes, okay?
I don't know if you know this, maybe this is new to you,
or you're like, you know what, that's old news,
but blood flow to the part of your brain is blocked
or interrupted,
depriving the brain of oxygen.
So, an ischemic stroke is usually caused by a clot,
a brain clot.
A hemorrhagic stroke can happen for a variety of reasons,
maybe an aneurysm ruptured.
They, maybe they're on blood thinners
and that caused some bleed, bleeding.
TIA is a transient ischemic attack.
They lost blood flow for a short period of time
in the brain.
Usually, could be a...
And, I don't wanna go into great detail,
but could be a sign of an impending, severe ischemic stroke.
So, there's different types of strokes.
You're learn more about them when you go to pathophysiology
and med surg classes.
But, I just wanna talk about that.
Strokes are a medical emergency, okay?
I've talked about time is tissue.
So, the faster you treat these ischemic
or hemorrhagic strokes,
the less damage the patient might potentially have.
Know the signs and symptoms of strokes.
Know the risk factors for strokes, act fast,
time is brain.
I see a question.
- Sarah, there's a question regarding the types of strokes.
Just, what are the causes for ischemic strokes?
- Clots, like maybe they...
There's, oh, there's a lot of reasons.
Maybe, they have like AFIB,
and that produced a clot in the heart
that went to the brain.
Maybe, they had a clot in their leg
that traveled up to their brain.
Lots of reasons, so.
Maybe, their blood pressure dropped suddenly
and that caused some spasming of the vessels in the brain.
And, that decreased the blood flow to the brain.
There's a lot of reasons.
So, I see another question, Dan,
Do you know?
I dunno.
- Sorry, it just said thank you.
There's no other question.
- Okay, stroke facts, up to 80% are preventable.
Treatment is available if we act FAST.
That's an acronym we're about to talk about.
Stroke can happen to anyone at any time.
Stroke is a brain attack, okay?
It affects the brain.
May have no residual symptoms or severe sequalae?
I can't say that word very well.
Dan, can you say it?
- Yeah, it's sequalae.
- Okay, good. Thank you.
For stroke, it just means
maybe neurological muscular changes due to the stroke.
So, sometimes the symptoms go away.
They regain full function over time.
Not, it's not like instantaneous,
and sometimes they remain...
They continue to have like left sided weakness,
even after the stroke.
It can also lead to a death.
I've seen that happen.
Stroke is the fifth leading cause of death in the US.
Family history of stroke increases the client's risk,
history of stroke increases the client's risk, okay?
And, I'm gonna take a break right here.
I'm gonna stop recording, just a minute.
Stop share.
And, I'm gonna give you...
Is anybody listening?
I'm just wondering if...
I know we have a respite day next week.
Is PRNU 1-14 doing virtual?
I don't know if they're out there.
- I don't think we've heard anything about that quite yet.
- Okay, thank you.
- At least I haven't. Somebody else might have.
- Okay.
I'm just curious if they were doing virtual.
I can ask Carrie, easily.
I'll just text her real quick.
I have another minute.
- [Viewer] When is the rest day?
- Hmm?
Oh, it's Thursday, the...
What is it?
The 15th.
- [Viewer] Thank you.
- So, you had said our first simulation was next week,
right?
- Correct.
- For us that are on, have lab on Thursdays,
will we just sign up for slots on different days then?
'Cause it's the respite day.
- So, you'll have your respite day.
No, you don't have to.
So, what we're gonna do is Dan's gonna help me on that day.
And, then we're one of, probably me,
will help Robin on Thursday evening, the following week,
and you'll do two simulations.
- Okay.
So, we each have both on the week of the 22nd instead?
- Yeah.
'Cause, I don't want you guys to miss out,
but I can't give you extra work for the week.
So...
'Cause of the respite day.
And, if anybody's listening, the first week,
it's therapeutic communication.
So, it's really like to wet your whistle,
to dip your toe in the water,
to kind of get used to simulation.
And, I'll talk about that in my short, short video
about simulation.
Simulation's really fun.
I've had to engage in simulation.
And, even for me, I know it's not real,
but you get into it.
If you let yourself get, kind of,
realize this is not a real patient,
but I'm going to learn something,
it allows you to kind of play the role.
I've done this for ACLS training, BLS training.
I've done this for, we had this scenario.
I can't really talk too much about it,
but where we...
It was an emergency situation
and we had to engage in the simulation.
And, I had to, at one point, I had to tell myself, okay,
Sarah, this is not real.
Like I got a little like... (screaming)
And, I was like, okay, this is not real,
but I'm gonna do it, because I...
No one's getting hurt is what I was thinking.
No one's getting hurt.
So, this is not real.
No one's gonna die.
So, okay.
I'm gonna start.
A couple things I just wanna mention,
I put it in my announcement, but April 12th, after class,
we'll do a group review.
It's not mandatory.
I'm just gonna do a full review of the exam for everybody.
So, hopefully that helps everybody.
And, plus, Dan and I spend like hours meeting with students
between the first and the second exam.
And, that just ate up a lot of our grading time,
which is fine.
It was fine that we met with you,
but it's just a lot of our time was taken for that.
And, we wanna make sure that we stay up to...
On track with grading,
we wanna make sure that we prepare sufficiently
for lectures and stuff like that.
So, I know, I know we have guest speakers,
but we still work with the guest speakers,
and meet with them, and look over their content.
So, it's all this time that we just wanna save,
but also give everybody opportunity
to review the exam all together, okay?
So, hopefully that helps you.
And, I already asked my other questions, so, okay.
I'm gonna, you can go off video if you'd like,
I'm gonna start recording again.
Okay.